Tooth Whitening Informational Consent Form

Eugene Family Dental

General Information

Tooth whitening is designed to lighten the color of your teeth. Significant whitening can be achieved in the vast

majority of cases, but the results cannot be guaranteed. When done properly, the whitening will not harm your

teeth or gums. However, like any other treatment, it has some inherent risks and limitations. These are seldom

serious enough to discourage your from having your teeth whitened, but should be considered when deciding to

have the treatment.

Almost anyone is a candidate for tooth whitening. However, people with dark yellow or yellow/brown teeth

tend to whiten better than people with gray or bluish-gray teeth. Multi-colored teeth, especially if due to

tetracycline, do not whiten very well. Teeth with many fillings, cavities, chips, etc., are usually best treated by

bonding, porcelain veneers or porcelain crowns. Any current restoration you have, such as, fillings, porcelain

crowns, onlays and inlays cannot be whitened.

Types of Tooth Whitening

In-Office Whitening – This process can usually be done in one visit. The appointment takes approximately 1½

hours. The advantage of in-office whitening include our doing all the work for you and in less total time than

you would spend whitening your teeth at home. The disadvantages include the normal inconveniences of any

dental treatment, such as having to come to our office to have the procedure done and having to keep your

mouth open for the duration of the appointment.

Home Whitening – This process, which can be done anywhere and anytime, involves wearing a custom-made

whitening tray filled with a mild whitening agent for optimal results. You should wear the gel-filled tray from

15 minutes per day to overnight, depending on the strength of the whitening agent. Most people see a

satisfactory result in 2-3 weeks of daily whitening and should discontinue usage when satisfaction is achieved.

The advantages of home whitening include performing the treatment when it is convenient for you. The

disadvantage to home whitening is that the success of the treatment is dependent on your commitment to

wearing the whitening tray consistently for the prescribed period.

Your Responsibilities

Wearing Your Whitening Tray – If you choose home whitening, it will only be effective if you conscientiously

wear the tray for the prescribed time for one to three weeks.

Complications – If you experience any severe discomfort or other problems, discontinue the whitening and

Potential Problems

Tooth Sensitivity – During the first 24 hours following whitening, some patients experience transient

sensitivity. This sensitivity is usually mild if your teeth are not normally sensitive. With in-office whitening,

this sensitivity will usually subside in 1-2 days. With some whitening, it may be necessary for you to reduce the

number of minutes or hours you are wearing the whitening trays or stop using them for several days to resolve

the sensitivity. However, if your teeth are normally sensitive, whitening may make your teeth more sensitive

for an extended period of time. Under these circumstances, you may choose to delay the whitening process

until we are able to complete desensitization procedures. If your teeth are sensitive after whitening, a mild

analgesic such as Tylenol or Advil will usually be effective in making you more comfortable until your tooth

sensitivity returns to normal.

Gum Irritation – This is the result of a small amount of solution coming into contact with the gums. This can

cause temporary inflammation and white spots. A burning sensation on your gums may also occur. This should

resolve itself between a few hours to a few days. You may also experience burning and/or swelling of the lips.

With home whitening, irritation can result from over filling your trays causing leakage onto the gum tissue.

Irritation can also occur if you are using the tray for too many hours when you first start whitening. It may be

necessary for you to reduce the amount of gel placed and reduce the amount of time you are wearing the trays

or stop wearing for a few days.

Completion of Treatment

Level of Whitening – There is no totally reliable way to predict how light your teeth will whiten. With in-

office whitening, one session usually significantly whitens your teeth. Some patients require an additional

session. With home whitening, it may take two to four weeks or longer of repeated applications to achieve the

desired results. There are no guarantees as to the degree of whitening of your teeth. The amount of whiteness

varies with each individual.

Relapse – Following completion of whitening, pigments found in food and drinks will restain your teeth,

commonly called whitening relapse. You may use daily whitening toothpaste, available in drug stores.

I have read the information provided and understand the whitening procedure. Dr. Thomas or their staff has

explained this procedure to me and all my questions, if any, were answered. I consent to this treatment.

Patient signature_____________________________ Date___________________

Witness signature____________________________ Date___________________